- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $202.16 / $202.16 / $315.43
| Facility | | $202.16 | $202.16 | $315.43 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $315.43 / $315.43 / $455.00
| Professional | | $315.43 | $315.43 | $455.00 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $97.00 / $117.71 / $158.36
| Facility | | $97.00 | $117.71 | $158.36 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $16.44 / $16.44 / $21.02
| Professional | | $16.44 | $16.44 | $21.02 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $38.18 / $41.95 / $108.52
| Facility | | $38.18 | $41.95 | $108.52 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2.48 / $2.48 / $3.10
| Professional | | $2.48 | $2.48 | $3.10 |